On my life

It’s August 2014 and it’s been too long since I've written anything here. A lot has been happening in my life. I’m happy, but a lot has happened.

Woodworking. I’m still woodworking. Still loving it. The last thing I've made is to replicate a plastic step-stool I have (because I’m short) so I can have one in my workshop and one inside the house. I've slowed down from buying tools too, but I can’t guarantee how long that will last.

Lego. I’m moving the Lego from the spare bedroom to a large display cabinet I got for my living room. I was hesitant at first to put them in a “fixed” position such a display cabinet or shelf, but now I much prefer to have them within easy view from the couch.

Work. Work is fine, but sometimes things frustrate me. On slow days I get frustrated with the fact that if I don’t see patients then I don’t get paid. On busy days I get frustrated with scheduling issues. Often I get frustrated with certain patients’ expectations of special treatment. More often I get frustrated at myself for allowing these patients’ behaviour, things other doctors or professionals from any other industry would not allow. Most days though something or someone will remind me why I do my job in the first place, and then I am satisfied.

Family. Well, not so much family as religion. I am still very dissatisfied with the way the religious group I belong to operates. My mother has to remain distant from me in order for me to protect her. And yet the threat isn't me; I am the one that loves her! The threat is posed by the religious group we belong too. I will admit that after my last blog, somebody confused a post I made on my facebook with the post I made about the things I love in life and told my mother some very vicious and hurtful lies about what I post online (she, of course, does not even use the internet to check things out herself). This resulted in my mother telling me she has never felt more ashamed of me in her life, and she is embarrassed of me because of the things I post online. Ashamed of me, of her daughter! Regretful of the fact I was born and the way I am. Yes, of me, and it’s not the first time she’s ever said that to me. And yet I love her and I know that in reality she loves me, but those words are the result of the religious group we belong too. That is sad. And there is nothing I can do to change anything. I can only love my mother, accept that she hasn't yet realised what I have (that we belong to a cult), and keep going about my life.

The last month. Gosh, I don’t feel I own this story wholly so I will try to remain respectful of other’s privacy and intimacies. In this last month I have at times felt so alone, at other times it was the closest I've ever felt to any other human being, so intrinsically-linked, so unbelievably happy, and then so terribly disappointed and angry. And yet, somehow, and definitely helped along because I know I am not alone, I remain hopeful. I feel I have this undercurrent of general positivity. I am strong because I am not alone. I feel strong because I choose to remain positive and optimistic despite some hell of an emotional roller-coaster. I feel like a soldier, but not a soldier on their own, but one that is part of an army. My army, our army, and though we may not win every battle, we are not beaten. I am so not done.

On medicine and public money in Australia

Recently I was at a meeting organised by a community pharmacist to “remind” myself and other general practice doctors about a scheme available to patients that not only can help patients, but just also happens to be remunerated quite well by Australia’s federal health care system, Medicare. And I mean it pays general practitioners (GPs) well, and it pays pharmacists well. Suddenly another GP in the room asked just why are we being paid extra to do this when as GPs we have little to actually contribute to this patient’s particular health care encounter. The room fell silent. I couldn’t believe that finally someone had said what I had suspected for some time but didn’t have the courage to admit: that in some instances, the government does misspend money allocated for health care. I know, it seems so counterintuitive, so out of place, to suggest this at a time when the Australian government is saying that health care funding is becoming unsustainable, that the need for it has made it such a drain to government funds that it’s become unaffordable to fund alone on public money.

So where are the holes in the bucket with public health care funding? Well, in the interest of open disclosure I will admit that it’s been years since I worked in the public hospital system. I work in private practice, but as most doctors in private practice, still work under Medicare rules and (federal) funding. What I mean by this is, although we work in medical clinics that are privately owned, we receive Medicare money for part or all of the work we do. The choice to accept Medicare funding as the whole payment for services provided (i.e. “bulk-billing”) or only as part of the total fee is each practitioners choice. And the choice is not as simple as “some doctors are greedy and some aren't”.

I’m not a greedy person, but I refuse to accept the inadequately-low fees Medicare offers as payment for most general medical consultations. Let me explain this with a simple everyday example. Seeing a patient for a general medical complaint in a consulting room for 15 minutes costs the medical centre about $65-$71. That is what it’s going to cost to pay the doctor, administration staff, building running costs, etc. Now, Medicare Australia only pays $36.30 for this service. The federal government pays that not because they have calculated that that is what it actually costs for the medical centre to actually fund this consultation. No, this has been a federal budgeting decision that says that that is all the government is willing to pay for this service. It does not take into consideration the medical needs of the patient, the individual patient’s financial situation, and it certainly does not take into account the real costs of medical practice today. So, the government has essentially given the Australian public Medicare cards that you could roughly equate to “50% discount” cards (when used in private general medical practice), but they have unfortunately gone and told them that they are “100% discount” cards. And what’s more frustrating than patients not realising this, is that they expect this, politicians tell them they have a right to receive healthcare from private practitioners that are 100% subsidised (what is commonly called bulk-billing) using their 50% discount cards. What happens then is that medical centres have to charge individual patients the difference of what it actually costs to fund their healthcare and what the government is willing to pay on their behalf – or you go to a medical centre that has adjusted their practice not to suit the patient’s medical needs, but to try to make the smaller money from bulk-billing stretch (I won’t go into their practices, but there’s a reason I refuse to work in that system). But that’s not the story the governments tells the general public, honesty doesn't win votes, what they tell the public is that doctors are charging them more because they are greedy, not because governments are not funding their healthcare adequately.

Having said that, let me now discuss instances where I feel funds are not best justified. Some years ago, it was brought to the government’s attention that there is a high incidence of mental illness in the community. This affects a large proportion of people’s health, and ultimately it also becomes a drain on the social welfare system. It was identified that psychotherapy could help a lot of these patients with mental health problems. So it was then decided to allow Medicare to fund psychologist visits if it was deemed by a doctor that this was likely to benefit a person’s mental health. In order to encourage GPs to asses patient’s mental health and subsequently refer them to psychology services, Medicare offered substantial funding to GPs to provide this service. Considering the high incidence of mental illness, the cost of paying GPs and subsequently also funding psychology visits, this resulted in a massive new/extra expenditure for Medicare. So although the government wanted to encourage extra referrals to psychologists, they wanted to make sure that people weren't being unnecessarily referred who perhaps didn't require it. To ascertain this, Medicare introduced clauses that referring GPs had to obey, things like how long the consultation  must last, what must be covered in the consultation, what things had to be recorded in patient’s charts and in referring letters, etc. As time has passed, these things came to lose their function: most GPs could take less than 20 minutes (one of the initial clauses) to identify that a patient likely was suffering a mental illness that may benefit from psychotherapy and write a simple referral for this. In fact, I would argue that were it not for trying to meticulously (and unnecessarily?) follow all Medicare clauses, this could all be done in the course of a single standard medical consultation. Remove the clauses, respect doctor’s clinical judgement more, and get rid of special extra incentives to GPs. I know, I know, how dare I suggest a “pay-cut”? I’m not, really, all I’m suggesting is a redistribution of public funds within healthcare.

I could raise a similar argument about other general practice activities that are all clunked up with a lot of Medicare clauses, that pay a lot money (and I say this only comparatively to other general practice activities like consultations [which are underfunded]), and that could be just as well performed by doctors without either the extra clauses or the extra money. I mean things like home medication reviews where it is acceptable that pharmacist are paid for, but it is hard to justify why doctors should also receive an extra reimbursement when we are already expected to review patient’s medications as part of a normal consultation. A lot of people also seek ‘care plans’ to be eligible for some Medicare-funded allied health services. Why not just trust that GPs can make an assessment in a general consultation that a patient has a chronic illness and would benefit from allied health assistance? And while we’re on Medicare-subsidised allied health referrals, why is Medicare funding referral for therapies whose benefit’s on people’s health is not widely accepted and tested as beneficial? Medicare offers subsidised consults with osteopaths and chiropractors for patients with chronic illnesses (on a care plan) who have been referred by a GP. Why? Even some private health funds refuse to subsidise this (due to their unproved benefits) and the Australian government thinks it is worthwhile throwing precious health care dollars at it?!

To maintain my focus on what I have more personal experience with, I haven’t commented on how public health care money can be misdirected in public hospitals. However, you can speak to many public health employees in Queensland and they’ll all be able to tell you that a lot of public health care money is directed to bureaucrats and purely bureaucratic processes. Now, I will give you a simple example of how I have noted this happening more and more – even from my end as a private practitioner in the community.

Remember how one of the “perks” of private health insurance in Australia is said to be that the patient can nominate which specialist they are to see? Well, the opposite of this is that if you attend a public hospital, there is no choice given and people are triaged on clinical need, etc. as to which practitioner they see and in what relative time frame. Well, a few years ago I could refer a patient to a public hospital outpatient clinic for review with doctors of a particular specialty and exactly that happened: the patient received a letter to attend an appointment to the outpatient clinic of a particular specialty. Do you know what happens now? That when I send a referral for a patient to see a general surgeon, for example, in a few days’ time myself and the patient receive the first of a series of letters. This first one says this clinic is heavily booked, reconsider the referral, and go back to your GP to discuss this further (I tell patients to expect this letter and to ignore it). The second letter is just for me, and  it says that the patient has been given an appointment with a specialist (but they don’t state who) but because of Medicare rules, could I please tick the name of the specialist on the form, rewrite my referral, sign this new referral form, and then fax it back to them. But the patient already has an appointment booked with a particular specialist so that’s the specialist’s name I need to tick (I have to call them to ask them who this is before I can fax it back to them), and they obviously already know the clinical details I had on the original referral or the appointment would not have been booked. After I return the form to this hospital booking department, the third letter (and the only one that needed to be sent, really) arrives giving details of when the appointment is booked for. I ask myself why all this bureaucracy? And more importantly, which of my hospital colleagues in clinical roles lost their income so that this crazy bureaucracy  could be funded?

On keeping quite

I've noted myself that I haven’t being writing as much as I used to, and I think that now I know why. I was trying to convince myself that it was because of lack of ideas, but that’s not the real (or at least not the whole) truth. I have been censoring myself. I know, it’s embarrassing but that is exactly what I have been doing for at least the last year.

It’s interesting that I started this blog to put down some of my rants, to share some of my stories, and essentially to say the things that I lack verbal finesse to say adequately. It was meant to be to express myself and my personal opinions. So what happened? I've been scared. It’s true, I have been.

It started because at one point I was asked by someone to not share stories about my romantic relationships because they felt that reflected badly on them. So I held back my feelings (which I am finally realising are solely my property) and tried to eliminate even commenting that I may or may not at a particular time be in a relationship. Then I was dissatisfied with the circumstances of a couple of the last few places I've worked, and yet too scared to lose my job (and suffer financially) for saying what I really think and what I think is wrong. Later I became scared to even comment about any social or political situations that I have opinions on, for fear that my opinions may unfortunately be seen as not simply my opinion but those of “a doctor”. I was at the time reading stories about people who happened to be doctors and also bloggers who were posting opinion pieces, and who later received attention or reprimand from medical registration boards because apparently doctors can only ever be doctors and never just be everyday human beings with opinions. I was scaring myself into thinking that I just wasn't allowed to have an opinion that may not ‘reasonably be expected of a medical practitioner by the public’ or that may not ‘reasonably be shared by my peers’. Yes, I was thinking in medico-legal terms. And I was afraid to post about things that concerned or bothered me about the religious group I attended for fear of it affecting my or my family’s standing and reputation within the congregation.

So what does Vanessa discuss if she can’t talk about love, medicine, socio-political commentary, or theology? Not much. Because those are the things that affect my life the most, the things that I want to talk about. So I almost came to a complete halt of this blog. But I've been feeling very frustrated and very tired in the last year, and I've come to the conclusion that there may be a correlation between my lack of self-expression and the ongoing frustration and exhaustion in my life. So my plan this year is to allow myself to regain my passion for self-expression, and to lose some of the frustration that comes from my self-imposed censorship.

Thank you for your support.

Nothing should come between a woman and her love for... mangoes.
This picture was meant to be an analogy for writing, but mangoes will do :)

On protocols

A lot of things have been troubling me this week. A lot  of those things I can't mention because they may get me fired, so let me just focus in on an interesting thing I have recently noted about me and "protocols".

When I was younger, in medical school, I wanted to just "know" things. I wanted things to have an answer. I wanted definites. But, of course, medicine is all about uncertainties. One lecturer once said that if you can't deal with uncertainty well then you're going to struggle with medicine. I struggled with medicine. I was either fortunate or unfortunate to go through the post-graduate medicine program where so-called "self-directed" learning was encouraged. What this translates to is "teach yourself medicine at home using these resources, pay the university exuberant fees for not teaching it to you, and then come for the exams". Needless to say, I was not a fan. Some people thrive on that style of learning, but I always felt it was a cop-out. The university kept saying something to the effect of "didactic learning is the devil", but I really craved that devil the closer to exams we got. I understood that you do have to develop your own clinical reasoning abilities, but teaching basic anatomy and physiology facts should be one of the things that the medical schools teach. Yes, we all learnt it eventually, but it didn't have to be as painful, if you ask me.

So as much as I craved instruction, teaching, and protocol (i.e. what to do when) when I was in medical school, as soon as I graduated, "protocol" became my enemy. As an intern in a government hospital one of the first things you will be told about is the protocols - hospitals are full of volumes of them! Sure, a lot get ignored at many levels of the business of running a hospital, but one faithful group of adherents to the protocols were one special group of people that as an intern you deal with a lot every day: nurses. I think nurses have a protocol for everything in hospitals, from their precious lunch breaks to when a perfectly good IV line should be changed. Don't get me wrong, I'm not "nurse bashing" - in fact many of those who have worked with me as the one off the odd doctors who was loves and has a has a lot of respect for nurses.  And I do think a lot of nursing and medical protocols are good and they're there to ensure things are done consistently, and also to acknowledge that in emergencies our brains go out the window and we need almost to be reminded almost even to breathe too.

But there were also a lot of redundant and annoying protocols. The hierarchy in nursing circles, as opposed to medical ones, however, is more immediate. So if you don't do things according to the protocol then the nursing team leader is right there on the floor to hold you accountable to it; whereas in medical teams, you'd be lucky to get a consultant/boss who knows the intern exists or has a name. Doctors also have a lot more autonomy to make clinical decisions and can therefore deviate more readily than nurses  from the protocols. Nurses in the wards especially hate it when doctors ignore their protocols! One of the more ridiculous protocols a nurse forced me to oblige to was to take from her hand a pack of medication and hand it to a patient personally because nurses aren't pharmacists and therefore weren't allowed by hospital protocol to "dispense" the medication to the patients personally. But doctors also aren't pharmacists, so I didn't understand why I had to walk all the way to the other side of the hospital to pass a box of medication from the hand of the nurse to the hand of the patient standing right next to her. What did I need to understand, though? All I had to do was to "follow the protocol" and obey the ridiculous request. Actually, I found it comical, and I made a big deal about coming up to the ward to carry out this all life-saving task.

Interestingly, now that I am the consultant in private practice, I have entered a quest to find all the protocols for general practice medicine that I can find. Did I suddenly develop an incomprehensible lust for protocols? No, I still haven't, but what I have come to realize is that in the "real-world" (the world outside of the hospital) our legal system requires that we have a good goddamn excuse for deviating from the protocols if something ever goes wrong for one of your patients. And the protocols in the real-world aren't about tedious and mindless obedience of procedure, but about things that actually put patient safety at risk. Let me give you an example, hopefully without revealing too much of what those things I don't want to mention are: Say a clinic owner asks me to do something a certain way to cut running costs; I could do what he says, but if my patient risks suffering because of it, you can be pretty sure I am going to prefer following the protocol that all my peers are encouraged to uphold in order to minimize risk to my patient.

Turns out I still am just like I was in medical school, wanting to just "know". That lust is still alive in me, although now not there just to be able to pass exams but in order to be better equipped to do the best thing for the patients who put their trust in us in their most vulnerable times: when they're ill.

At my "other" job.

The goals and business of general practice

In the last week I have been involved in the recruitment of a new nurse to the primary care clinic I’ve been working in. (And I should note that the terms general practice, general medicine, and primary care, are been interchangeably here) I suggested that we ask applicants in the job interview what, in their opinion, are three goals of (private) general practice medicine. This is a question that potentially has dozens of answers! To patients, up to 95% of the time it is about helping them deal with immediate, though generally non-urgent, health problems. The rest of the time it is about preventing ill or worse health. To governments, the goals of general practice medicine are to keep people healthy so that they utilize less government-funded health resources. General practice is meant to keep patients out of hospitals. But what are the goals of primary care medicine if you happen to work in a primary care clinic? I think that if you understand the way the business of general practice, the goals of general practice are fairly straightforward - from a business perspective, because this is an industry just like many others.

How does general practice work? Well, patients require a service so they contact the practice’s administration staff to book this service: a medical review with a doctor. Booking appointments is just one of the tasks of the admin staff, and their tasks are fundamental to the proper and smooth running of the practice as a business and also in optimizing the clinical interaction between the patient and the doctor. The doctor takes the patient’s clinical history and requests investigations and treats their condition, etc. To do this more efficiently and effectively, they often enlist the help of the practice nurse. The nurse has a very important part in the running of the practice too. They are there to advocate for the patient, to help carry out a lot of the preventative activities related to medical practice, they administer medications and immunisations, they perform some of the tests the doctor needs to help clarify the patient’s diagnosis, etc. They do all this in the background so the doctor doesn’t need to do it herself – and in this time the doctor may see another patient or take care of another clinical activity. That’s it. At the end, the patient pays one fee to cover the cost of seeing the doctor, the nurse, and having administration staff assist them.

How General Practice Works

Now, how does the money side of general practice work? There is one source of money coming into the practice: patients. That’s right, the only income-generating activity in general practice occurs in the interaction between the doctor and the patient in that room. For example, talking to the receptionist doesn’t attract a fee (as a patient you could theoretically come in and talk to one all day and she can’t bill you for anything as she hasn’t sold you anything).  

Where the money in General Practice comes from.

What then? Well, the money generated by the doctor’s fees is pooled and is meant to cover the cost of paying the practice’s staff, the building rental fees, insurance costs, medical and non-medical equipment costs, etc. And that exactly is why it is important for practice managers, for administration staff, and for nurses to help doctors see more patients and to see them efficiently and effectively.

Where the money in General Practice goes to.

So what are the business goals of general practice? I believe they are so closely related to the duties of general practice that you could be forgiven for mistaking them. The first priority of (any) medical practice are the patients. Keeping them well, that is giving them what they pay us for (assistance with health problems), is and needs to be the first goal. The second goal is to optimize the interaction between the patient and the doctor; the “service” being sold. It is the task of everyone working alongside the doctor to make sure this happens well, smoothly, and in a time-efficient manner. The third priority is to the community in which we work. This makes sense not just in a humanistic ideal but because general practice, as opposed to other medical specialties, often deals with people who are well and healthy – and who want to remain that way! Healthy patients don’t attend cardiologists, for example, to prevent cardiac disease. No, they would go see the cardiologist once cardiac disease is diagnosed or suspected and they need secondary prevention or treatment. But general practice does see well people for this and many other preventative activities.

It makes so much sense from a business point of view to fulfil our duties in general practice, that is to patients, to the staff, and to our community. Patients that are well-cared for and feel/know that they are being prioritised want to continue using that service. If you optimise the doctor-patient interaction (in business terms: time), you make the business more profitable. And if you cater to the local community, that community gets to know and trust your service and seek it out amongst the other dozens of similar practices around. What is there to lose by fulfilling the duties of our jobs in general practice, really?

On responsibility

I remember one of the greatest lessons taught to me both at home and at school was about responsibility. It was such a good trait in a person that even if you owned up to wrong-doing, there would be an incentive for the admission (e.g. reduced punishment). I wonder now what happened to make taking responsibility for almost anything such a dirty affair.

Do you know when people are quick to claim responsibility for things? When things go right! Politicians, for example, are a great at speaking of their triumphs in war, claiming they achieved this or that target. For a moment it would be possible to convince yourself that Barack Obama was literally holding the firearm that killed Osama bin Laden, such was the claim that “we got him”. In science journals a string of names appear as the “researchers”, and if the discovery or finding is big news enough, the person giving the interview will be the person who runs the research institute or the head of the lab – not the little guy who actually did all the intellectual and physical work. Similarly in medicine, especially in teaching hospitals, the name of the consultant will always be quoted as the guy who did the surgery or who treated a patient’s complex medical problems – where in reality the consultant probably has never laid eyes on the patient. But I am, of course, talking about when things go right, the successes. The culture extends all the way to clinical records, as I have had to explain to patients in the past:  “I know the information is about you, and it was collected and written by me, but it belongs neither to you or me apparently but to the person who lent me the pen and paper (or computer) with which I recorded the information”. Or at least this is what I have been told in the past by previous employers… Imagine if the same had been done to the great poets and writers of the past. Mark Twain would not have made a cent from the proceeds of the sale of Huckleberry Finn but the manufacturer of the pen and paper he wrote with would have made some very easy money!

Now, when things go wrong in medicine, it’s not the hospital’s or the clinic’s fault, it’s not the consultant’s fault – then it is all about the little guy. When competitions are won, a whole nation claims victory; but when they are lost, it’s the one competitor or team who is the loser. When corruption is uncovered, it is always said it was just one person’s fault, not the institution or the culture that drove him to it, etc. We have become very quick to deny responsibility for ourselves and distance ourselves from all negative events. Unfortunately, this has come to extend to our personal lives too.

If there is one thing I pride myself on is trying to be an understanding and non-judgemental human being. I have met people, though, who confuse taking responsibility with admitting fault, and therefore they refuse/avoid/delay taking responsibility at all. We are all shaped by our childhood experiences, past relationships, our genetics, formal and informal education, etc. All these things together shape how we are today. Now, one or more of those things may have been a profound traumatic negative experience that has gone on to shape us significantly – and maybe even negatively. As a result of that experience perhaps we become highly attuned to certain words people say (perhaps words bullies may have used) or to misinterpreting body language or we come to expect that certain words will be followed by physical abuse, etc. When you experienced those things before it was perhaps appropriate to retaliate or go on the defence. The thing is when you are no longer in that situation and you continue to react as if you were, that is when our own actions/defence become our offense. That is when we hurt ourselves more, or others too. Now, as I said, I can understand this and I can forgive this. No one is saying it is your fault you are the way you are; and it’s certainly not your fault those negative things may have happened to you (emotional or physical abuse, etc.), but it is each individual’s responsibility to decide whether they want to continue to be and act the same or to change. I see the person who refuses to change, who points out how it’s not their fault, who perhaps feels guilt but not motivation to change, as someone caught up in victimhood. And as I have stated many times before, we are not victims of our past but rather the creators of our own future. And trust me, there are still plenty of incentives out there for those that do stand up courageously and take responsibility.

On levels of evidence

A patient asked me the other day if I thought she was a crazy person for telling me she was going to disregard my advice on managing her high cholesterol and high blood pressure and go have a chat to her naturopath instead. I said no, that doesn’t offend me at all. Actually, it has nothing to do with me. I had explained to her the risks of untreated hypertension and hyperlipidemia and about how medications can help those, etc. etc. I had disclosed sufficient information for her to make an informed decision on her own health. She has a right to refuse treatment just as I had a duty to provide that information to her as her treating doctor. Medico-legally, I was in a defensible/safe area. Aside from that, though, did I think she was crazy for refusing well-advised medical opinion? Well, no. And this is what I told her.

You know, I believe in God. I believe in the Judeo-Christian version of God and in creationism. I’m comfortable in believing these stories that if you applied the scientific level of “proof” are actually quite laughable. So how do I get around holding such preposterous beliefs and still having some sort of pride in calling myself both a Christian and a scientist? I don’t apply the same level of proof or set of rules to all my beliefs. And yet, why do I believe the Christian and not the Islamic or Mosaic or Taoist or any other version of life philosophy? A whole heap of reasons! Probably because the country I grew up in had 99% of its population listed as catholic. Probably because my family is Christian. Probably because Christianity was all around me and the stories were told to me since I was very young. I was told from very early on also that the people who lived in my house were my siblings, my mum, etc. and I believed it. Even now I do not see the need to demand DNA-evidence to “prove” the story that these people are related to me. Similarly, I was told stories about God and Jesus and prophets, etc., and I am happy still to believe them. But what has all this got to do with my initial story about the lady who wanted to see the naturopath?

I’ve been trained in Western Medicine. I have a system in my mind with which I approach illness and human functioning. Briefly, I studied anatomy and physiology and pathophysiology so I believe 1) The body has these organ systems working together to make the body function in the environment, 2) The body is trying to stay “alive” and function properly as it’s default, 3) When the body is failing at functioning, it is because of an illness, 5) Illness is brought about by microscopic processes, be it errors in naturally-occurring processes or external microscopic organisms bringing about this change. That’s it. That’s essentially the Western Medicine model of disease. When we approach illness, we are trying to restore the body’s function to its default. We give medications or we perform surgery to try to restore this balance somehow. We may also advise modifications in diet, physical activities, exposure to the external environment, etc. The “treatments” we recommend are based on scientific evidence that they have some effect on illness.

I am comfortable with the model of medicine I have been trained in. I am comfortable with the level of scientific evidence it demands. Because I’m both comfortable in this system and believe in the scientific method and the stringency demanded of the “treatments” in Western Medicine, I find it hard to accept other models of medicine. Is that a bad thing? That is akin to asking ‘Is it bad that I’m a Christian and not a Jew?’ No; it isn’t a bad thing. It’s what I’m comfortable with, what I know and understand, and the alternative is unknown to me. Alternative models of medicine are to me as foreign as Zoroastrianism. Because these things are largely unknown to me, I lack knowledge and exposure to them, and –importantly– I lack belief in them, it’s better that I stick to the kind of medicine and the kind of religion I know and believe.

Now, back to the point of scientific evidence. The model of medicine I practice in, Western Medicine, what I simply call medicine, has a few postulates that to me are important. For example, it demands that the positive effect of treatments be reproducible, that side-effects are minimal and predictable, that treatment is better than no treatment (and by a significant margin), and that the treatment has been tested many times over for safety. The treatments supported by other models of medicine may lack some of these stringent criteria in favour for other priorities (e.g. that it is derived from ‘natural’ products, etc.). As I said, to me (and for the majority of my patients), the level of scientific evidence that Western Medicine demands is all-important. But if others are happy with an alternative model of medicine and alternative levels of evidence that they demand of their treatment, then I can only respect that in the same way I see it as my duty to respect other people’s religious, cultural, and other beliefs.

For example, I have patients who tell me, against widely-accepted scientific evidence, that they don’t believe that smoking is bad because their relative smoked until the age of 100 and died of causes unrelated to smoking. This person requires a study of only one person who is significant to them to make their conclusions. Or they may tell me that their friend down the road told them that sunscreen causes skin cancer, and that is why they refuse to wear it. This person, again, requires only anecdotal “evidence”. Or they may tell me that blood-pressure-lowering or cholesterol-lowering drugs cause more harm than good, but the arsenic-containing but “natural” compound sold by their naturopath is the best thing for it. This person believes that a product being “natural” means it’s automatically safer and more beneficial than one that has been rigorously scientifically tested. What can I say to these people? Well, usually nothing that will change their minds if they don’t believe in the model of medicine I have been instructed in. But what I usually do is explain to them in Western Medicine and scientific terms why I believe the treatment Western Medicine suggests is appropriate, what the risks are of not treating it this way, and then ask them what else they wish to know about this particular treatment. After that, it’s up to the individual patient to make their own choices. And no, I don’t think of them as crazy for ignoring my advice :)

On being a GP

A few weeks ago I wrote a mock lecture for a friend who is a nurse to “upskill” her into becoming a doctor. It was something I wrote in jest with the intention of training her to do my job (so she could see my patients while I went home to sleep). I was going through the files on my computer today when I found that “lecture” again, and I got to thinking how actually, it’s not that hard to do my job! I will show you now why I say this, incorporating part of my lecture. Think of this as something like the general practice version of the 'The House of God' rules :P



Yes, these treatment options apply to everything.


OK, now that the basics are covered – and remembering that the safest thing you can do in general practice is to do nothing, here is a more detailed (using the term ‘detailed’ in a very loose fashion) run down on the medical aspect of illness, by organ system.

Now, if you remember just a few of those things, you have very close to the medical knowledge of an Australian-trained GP. (You don’t even really have to worry about knowing how to do a physical examination. I mean, have a look at rashes and things patients like to show you, but it’s rarely going to be essential that you lay even a hand on them!)

On asking the clinically-relevant questions

There's a question out there in medical land that apparently asks whether you are racist or not. The question is: "Do you identify as of Aboriginal and/or Torres Strait Islander background?" Now, the response to this question  – which in Australia IS of clinical relevance – is not what matters, but the fact that some people are unwilling to ask this question in this first place for fear of "offending" a person who isn't of this background.

Fear of offending a racist person is the reason some people give as to why they feel uncomfortable asking the question. They imagine they may encounter a racist person who'll take offense at not clearly being identified as non-indigenous. More specifically, though, they fear that they'll meet a non-indigenous person who they will offend by implying the negative stereotypes associated with people of Aboriginal and/or Torres Strait Islander backgrounds. But who's given this question that connotation? The racist person who holds those prejudices – and that is the person fearing to ask the question! You don't know the strangers mind that you'll be asking, only that you imagine it may believe what you (either consciously or subconsciously) believe yourself.

And briefly before I leave this topic, let me explain why I say that it is clinically relevant to know whether a person is of Aboriginal and/or Torres Strait Islander background. In Australia, there is difference in the life expectancy, the mortality rate, and the burden from disease between indigenous and non-indigenous Australians. This difference is commonly referred to as “the gap” between indigenous and non-indigenous Australians. Clinically, a person may be more likely to suffer from one or another illness (e.g. diabetes mellitus) if he comes from an indigenous background than if he doesn’t, and his/her symptoms may be more likely to be caused by a disease that is more prevalent in those of indigenous background than those that aren’t. This is turn is relevant to both the adequate diagnosis and treatment of this person’s illness. Further to that, the government may have incentive programs aimed at “closing the gap” in the health of indigenous and non-indigenous Australians, some of which can be quite helpful in allowing indigenous persons to overcome some other indirect/social difficulties in accessing adequate health care. So, asking whether a person is of Aboriginal and/or Torres Strait Islander background needs to remain a relevant clinical history-taking question, and one devoid of prejudice from the person who has been tasked with the job of looking after the health of a community consisting of people of all types of backgrounds. And perhaps we should stop fearing to encounter a racist person if it will only make us become the racist one ourselves.

On anxiety in medicine

One thing we don't often talk about but which keeps so many people back from their lives is anxiety. I mean, of course, not the anxiety we all feel at understandably threatening or fearful situations; I mean anxiety which affects the way we live our lives, how we express ourselves, how we work, and our health. The best way someone explained anxiety to me is like asthma: your body is responding to a fairly harmless substance as if were something extremely dangerous; your body launches a response aimed at this harmless thing and the response itself hurts your body more than the harmless thing ever could!

Imagine a military battalion being on edge awaiting for an enemy strike. Suddenly a white sheet of paper gets flown into your team's territory, the area you're meant to be protecting. The area has been quite for so long, peace was declared years ago, but your troops remained on guard as if it was still in the midst of war. When the harmless piece of paper gets flown into your troop's protected area, no one knows what's going on and no one has time to think it through. Instinct kicks in. Fire!!! The troops launch an attack. Bullets go out, grenades, bombs, all and every weapon available is used. Eventually everything goes quite and you evaluate the damage: there's giant craters and fires burning throughout your own territory and your team's supplies are exhausted. What to do now? You restock your supplies (this costs your government money, time, and effort). You rebuild the areas of your territory that were damaged, and as you do so you curse that stupid piece of paper that brought all this about. You hate him now... Then one day another piece of paper will enter your territory again. And guess what? You will do exactly the same thing! You've come to believe that the enemy IS that piece of paper. The reality is that the real enemy is that jerk who let your troops keep believing there was still a fervent war going on, and the fact that you have now forgotten to think and evaluate each threat as it arises and are acting purely on instinct.

Anxiety works exactly the same way. The reason it arose was probably no fault of your own: you've probably lived through a war that required you to be on edge all the time. But now what? The circumstances changed and so must your thinking, otherwise you risk causing your own self more harm than the anxiety/worry/fear is worth.

In my job I meet a lot of people who give up on their own health due to anxiety. Sure, there are sometimes when I see the bravest of patients who present to me asking specifically for help to deal with the anxiety which they've realized is destroying their lives. I'm not talking about those people - they've already done the hardest part: they recognize their problem and have sought help for it. These people have victory guaranteed because they've already overcome the greatest obstacle! The people I am, however, wanting to discuss is those who still cannot identify their problem and believe their ill health is due to bad doctors, bad medicines, bad surgical procedures, etc.

Sometimes I see patients who refuse surgery for, for example, skin cancer. Why might they do that assuming they already know that cancer is a bad thing and they don't want to have it? Because the plastic surgeon who would remove the skin cancer from his face was a bastard and he wants nothing to do with him. Ok, so I suggest another surgeon. The second (and later third and fourth) is also a bastard! Wait, wait, wait, what's going on? Eventually I find out that the patient is really terrified of having surgery on his face - and until he gets over his fear of facial disfigurement every surgeon will keep being a bastard! I've seen the same time and time again with patients who have gynaecological problems, gastroenterological problems, cardiological problems, haematological and almost every other type of medical problem. I've had specialists ask that I please re-refer patients after they've had psychotherapy to deal with their anxiety. It ends up delaying treatment, and some patients go on to refuse treatment altogether.

What can I do? Many patients you just can't convince that it's not that every doctor is a bastard or has mistreated them. You can ask the questions and have the evidence right in front of them that this person has a debilitating anxiety problem but same as you can bring a horse to water but can't make him drink it, you just can't help those who refuse to acknowledge their greatest problem. What I sometimes do is tell my patients about these troubled army troops that keep attacking benign enemies and end up causing themselves greater harm than the "enemy" ever could. Do you think these troops might benefit from some retraining to help them better evaluate the enemy and launch and adequate response when it's due? Yes? I'd like to do the same for you, and I know just the person to help you with some retraining. This person's role is called a psychologist. Seeing him is not a sign of weakness but rather about redirecting your strengths where they're actually needed.

It is always such a shame to see people walk away with gynaecological cancers, thyroid cancers, valvular heart disease, severe renal failure, etc. who keep telling me that they'd rather die than see another horrible specialist. What I hear is 'I'd rather die than deal with my anxiety'. It's such a shame.

On memory

I came across an email I wrote a few years ago and it was about something that happened to me in 2007. In 2006 I took some time out of medical school for reasons I’ve discussed many times in this blog. The thing is that in 2007 I returned to finish off my medical degree and I kept running into people I’d known previously from medical school – and they were all surprised that I had returned! The only person, it seems, who wasn’t surprised that I returned to my studies was myself. And yet I struggled to understand why people were surprised given that I never once considered it a possibility of not returning.

Here’s part of the email I wrote to my friend (and, yes, I do write very long emails):

Being back at the hospital I am often running into guys who knew me from a few years ago, and its so weird. Some of them (I guess the ones who knew me a little) tell me that they’re glad to see I came back into it, back to med. This girl even gave me a hug the other day and said exactly that! Now, in my mind I can’t remember ever being as unsure as these people seem to be that I would return. When I decided to take leave, I knew it was just a break, that’s what I wanted, and I don’t remember doubting that I would return, only doubting that if it was to be one rotation off or the rest of the year (that’s all the options the school offered me). But maybe I was projecting something different. I don’t know now, I’m confused. Maybe other people were projecting onto me and doubting my commitment or abilities more than I was. It’s so strange; I don’t recall being that unsure.

I remember feeling empty and alone and overwhelmed - and the insomnia- but it wasn’t even the lowest I have ever been. By comparison that period wasn’t even that bad or even that long-lasting. And I remember a few months after I stopped doing med in 2006, a friend of mine (and I mean a friend not an acquaintance) said to me “you’re not going back, right?” I thought that comment came out of nowhere and I was a little offended, because even at the time of that question I was very convinced that I would – and actually looking forward to returning to med the following year. 

My family also had countless talks to me telling me that I should return to med. I felt it was so pointless because they spoke to me as if trying to convince me of something that was against my will, whereas I felt ‘of course I won’t counter-argue because we both are thinking the same thing’. It was absurd. But of course, I knew that some of them were telling other members of my family that I was a loser who was incapable of finishing a real uni degree. 

And then there was my therapist, who probably knows me better than most of the people in my life and is familiar with most fragments of who I am. She also asked me before I started back, if I actually wanted to go back. Returning to med was never an issue as far as I was concerned; when I would was the only issue present at the time I decided to take time off. And she had known me since before I started to feel all the negative stuff that made me want to take the time off. 

So, my question is: why did everyone doubt that I would return to med; what have I forgotten from that time? Why do I forget? And what else am I forgetting? It’s scary, you know.
The only explanation I can think of for my old acquaintances saying they’re ‘relieved’ to see I came back into med is based on another theory of mine. After I’d already been on leave a few months 

I told two acquaintances of mine from medical school that I was on medical leave. So, my theory is that these two boys must have told a pretty drastic story of how I was and why I’d had the time off. I figured this after I ran into some people and to catch them up on my story I’d tell them that I was a year below them because I’d had some time off – and yet most people already knew that even though I’d only told two people in my course.  They all added that they were glad I had decided to come back. What decision to come back?! I had never doubted whether I would or not. Unless I am forgetting something. Am I forgetting something? 

It’s pretty confusing. I am scared of becoming convinced of something like 2+2=5 if you tell a person enough times, like in that book 1984. Maybe the whole world is really like that, and the world trade centre really just fell accidentally and there were weapons of mass destruction in Iraq and you can convince a person that the world has always been the way it is and nothing of the past atrocities brought us to this “progress”. But then what do memories serve us for? To confuse us? To make us suffer because of the incongruences?...

What I’ve come to realize since the time I wrote that email is that in this world it is dangerous to believe what others tell you about yourself. Hitler, for example, surrounded himself with yes-men, people who agreed with his every word and told him his every idea was genius. Isn’t the same equally true if others are constantly beating us down and telling us what a failure we are and how unlikely we are to succeed? We need not surround ourselves with only our worshippers and we don’t have to believe our oppressors, but the truest stories are sometimes those we write ourselves. The story of Vanessa is best written by Vanessa; and if I want to describe a positive person, then I have to build my story to allow myself to become that positive person. It’s taken me a while to figure that out, but my story is a work in progress.

On prescription drug abusers

Every now and again all doctors will come across a person who wants to access prescription medications for the wrong reasons. Some people will want them to feed their own personal addictions, and others will resell them for a profit on the streets. Personally, I am never one to judge people for their weakness or for their lifestyle choices, yet this scenario bothers most doctors for a variety of reasons. It bothers me because the false stories these people tell will make me second guess and misjudge the person who tells the same story but it is true and they have a real need for these medications. And, yes, it is also frustrating to have to deal with patients who are lying to you or who abuse your trust or become aggressive/threatening when you challenge them or deny them what they want when all you’re trying to do is get on with your daily job.

There are some government systems in place to help doctors identify people who abuse prescription drugs, but unfortunately they have big limitations. The biggest reason they probably don’t work is that a doctor has to first decide to enquire with them about a specific patient. Now, the patient who is a prescription drug abuser usually knows how not to arouse suspicion from doctors – therefore the doctor never decides to check their background! In medical school they taught us some basic things that should arouse our suspicion that a patient may be a drug abuser, but most drug abusers have figured these out and found ways to deal with us to make us believe they aren’t one of those people we learnt about all those years ago. For example, some of the things we were taught are that drug abusers tend to:

•          book the last appointment of the day (no, not anymore. If anything, they tend to be morning people)
•          ask for specific medication (they know how to calculate equivalent doses of whatever you give them if it’s from the same drug class. They also know to ask for an NSAID and paracetamol along with their opiates and benzos)
•          can’t back up their stories with clinical data (they have scars to prove the “surgery”, the medical report from the hospital, the clinical signs on examination, the old packets of the medication they have been prescribed, the imaging report, the name of the interstate specialist who looks after their condition but is unfortunately unavailable right now, etc.)
•          they become angry if you question them about drug abuse (“Oh no, doctor, not me. You can even call my specialist – oh wait, he’s not there today”…)
•          refuse referral or liason with other clinicians (you have to admire these guys’ confidence in their lies. I once was  informed by a hospital oncology department that I was the 15^th GP that week that had referred a patient for urgent review– a patient who did not actually have the metastatic cancer the CT report he provided from his interstate doctor, a doctor who knew nothing of the patient either)

Most doctors agree that a solution to the problem of prescribing to patients who abuse prescription medications is to have a real-time system of prescribing where the doctor is alerted to how many times a drug of abuse has already been prescribed to a patient. Would it work? Maybe, or maybe not. I hope it does if it's ever introduced.

To be honest, what bothers me most about the issue of prescription drug abusers is not that I was once duped by an amputee who claimed to be a war veteran but who had in fact lost a limb from intravenous drug use related disease (and not a war injury as he claimed) and I gave a script for opiates to. But that that experience made me doubt the next amputee war veteran I saw who had lost his limb through war injury and had severe phantom limb pain for which his pain specialist had prescribed a whole concoction of drugs, including opiates. Had his specialist not been available and his story backed up, I may well have let him go without receiving the proper medical care he deserved. That is my greatest fear regarding this: not that I feed a junkie’s addiction, but that I commit an injustice to a real and deserving patient.

On alternative medicine

The most “open-minded” thing I’ve done this year is to try this so-called natural medicine thing from a consumer point of view. Whenever I tell this story people almost gasp in disbelief: Yes, me, an Australian-trained doctor trying this thing we have been taught since medical school is mostly witchcraft. And yes, I admit, that is (or at least was) my own view on this. The common medical literature tells us “natural medicine” is not scientifically-evaluated, poorly understood because for the most part it’s not in line with the common biopsychosocial model of medicine, and that it’s potentially very dangerous.

Sometimes patients ask me what my views on natural medicine are, and essentially they mean to ask my medical opinion on whether certain natural medicine treatments will help their condition or not. My response is almost always the same: “If you believe it’ll work, it probably will. If you don’t, it won’t”. I don’t know if that’s true, but I’m pretty close to certain that it is true when we are talking about homeopathy. My response is also an acknowledgement to the God-blessed and irrefutable placebo effect. And that is about the extent of my knowledge on non-Western (or alternative) Medicine.

My experience with alternative medicine until a few weeks ago did not leave me with the best of impressions, and they were mostly experiences I had had through my patients. However, before starting to share some of these experiences, I would like to say that I don’t intend to vilify or defame something which I have just admitted to understanding so little, in telling these few stories.

The most recent gimmick I fear for my patients sake are the “full-body scans” that promote themselves as being ‘scientifically-proven’ for the diagnosis of a multitude of vague complaints. They spit out beautiful 3D images and buzz words like “inflammation” or “congestion” and the name of a body organ. Patients pay hundreds of their dollars for the beautiful colour printout they get after having their temperature, blood pressure, pulse, and maybe even respiratory rate measured. But the point is they get what they want because some manufacturer has figured out how to give the patient what he wants (to be taken seriously, to feel cared for, education about his condition, etc.) in exchange for what he wants (money). Oh and how it breaks my heart to have my patient come back to tell me he has stopped taking all his heart medication because the printout said nothing about anything being wrong with his heart only about his spleen being ‘congested’. Or sometimes they’ll come back with a list of obscure tests the naturopath or someone has asked he have checked though you think they are not clinically indicated. So you explain to the patient that those tests may be performed privately, with the cost to the patient, and suddenly they think you are the devil because you are the one who told them about the cost even though it’s not a price you’re setting or something you even think they need… There are many frustrating stories out there from clinicians whose patients have sought the services of an alternative medicine practitioner and some have happy endings and some drastically worse, but what I really wanted to share this week was about my personal experience.

Now, a few weeks ago I allowed my mother to talk me into trialling some “alternative medicine” through a Chinese medicine practitioner one of her friends had recommended. This is the common referral method in this field; word of mouth. So I went along to see this gentleman about a vague diagnosis of “depression” which mum had noted I had increasingly being struggling with (since a recent change in my life circumstances, so probably not even real clinical depression but a temporary low mood). But, hey, I thought I had little to lose so I went. The nice Chinese man with only basic English began by taking a routine medical history and a brief clinical examination (checking some aspect of my pulse and looking at my tongue). He asked about medication I was taking, and after looking at my tongue told me I had a problem with indigestion and ‘loose stools’. He also said I don’t like change and that is why I had “depression”, it was so easy, he said, to see that in me (I call that being human, but whatever).  And he said he could help me if I followed him. Then he took me to another room for acupuncture.

As I lay down on the bed, knowing how “well-educated” people consider me to be, I felt I truly had no idea what was going on and what was going to happen or the mechanism by which it was meant to help my very vague collection of symptoms (including the ‘loose stools’ or ‘indigestion’ which I had not noticed or even bothered me before, and the reactive low mood in response to some changes in my life). I remembered what I told my patients, and I decided to trust the guy about to stick needles in me. I wondered if he could sense my ambivalence and distrust, but truth is it doesn’t take any kind of professional to recognise that in another human being. I wondered just why I was going along with this: To “cure” myself of ailments I probably didn’t even have? To please my mother? To see what all this ”quackery” was about? I think it was a combination of all the above, but despite my reasons, I knew there was nothing imaginary about the needles about to pierce my skin.

He came back in the little cubicle with (to my relief) sterilely-packed acupuncture needles and ethanol wipes. He inserted 11 needles in me, on both sides of my body: 2 near the fibular head, one posterior to the medial malleolus, one on the palmar aspect of my wrist, one just behind each mastoid process, and a final one on the very top of my head into my scalp. What I’ve always being told about acupuncture is that they use tiny tiny needles; what I didn’t realise until the day of my first session was that these tiny needles still hurt! After I had the needles inserted, I was left in the cubicle for 30 minutes and a soft harp music was played over the speakers.

I didn’t know what I was supposed to think about for those 30 minutes, so I started thinking all sorts of things. I couldn’t move because every time I moved, sharp stabbing pains would shoot through the spots where the needles were in me. First I thought I was meant to focus on the music and just relax, however I was in the middle of an Asian-dense shopping centre and people were talking and shouting and that kept distracting me. Then I thought I might focus at the point tenderness the needles were causing me, but that got old pretty quick too. So I started to try to decipher how the whole acupuncture thing works. The guy who put the needles in me hadn’t explained it to me, but actually I remembered that one session in medical school where we briefly discussed about alternative medicine. It was something about Chi channels, which don’t correlate to lymphatic or nervous or vascular channels and have possibly no anatomically corresponding structures to account for them. Then something about the balance of the Ying and Yang, which are some metaphysical constructs related to health and life in general… Oh Gosh, I was half making it up and I was still no closer to understanding what I was at that moment meant to be going through.

Finally the 30 minutes were over and the Chinese medicine practitioner told me to get up and follow him. He asked how I felt. Um, I felt like I had just had being laying down for 30 minutes listening to relaxing music while having needles pierced in my skin. What was I meant to feel? Spiritual enlightment? Physical invigoration? Relaxed? I felt relieved, honestly, because my neck was sore and I needed to change my posture. So that’s what I felt, relief; but I didn’t think that that was what the nice Chinese man wanted to hear so I said I felt “better”. I remembered how I sometimes treat patients for things they don’t fully understand (though I try to explain) like hypertension. I tell them the medication won’t make them “feel” any different, let alone any better, it’s not meant to. They may not feel sick, but untreated high blood pressure increases you risk of things no-one wants to have like heart attacks and strokes. So they take the medicines I give them though they don’t notice any change, except maybe some side-effects, and they trust the 2 minute explanation I have given them as to why it’s good for them. I felt a bit like that with my Chinese medicine practitioner, though he asks me how I feel. I like this guy, he’s a nice man, he is trying to achieve something with me here, so though I don’t know what the right answer is, I don’t want to call either him or myself a failure... Better, I must feel better.

He charges me more than I would charge a patient for a consultation of equal duration and he picks out some pill boxes from his shop, all in Asian writing I can’t understand. He says take 40 of these tablets twice a day. What?! No, no, it’s fine, he says. He tells me he can “guarantee” they aren’t going to cause any side-effects; that they are free of these evil “chemicals” the medicines I prescribe have. Of course, they are “all-natural”. I ask what they are. They are “natural remedies” with “natural” ingredients to treat my loose stools and indigestion. Oh yeah, those things that weren’t even causing me any discomfort. He books me in for a further 4 acupuncture sessions which will make me feel even “better”. My heart sinks because my mother has heard this whole exchange and she’s ecstatic!

I went along to the other 4 sessions, my mother kindly driving me in and even offering to pay my fees. My mood is still a bit low and my self-esteem a bit shattered from the personal difficulties I had faced a few weeks earlier, so I don’t have the courage to say no. I even take the 80+ tablets twice a day for a few days until I get constipated… At my second acupuncture session he asks whether I have stopped taking my other “non-natural” medicines yet. I didn’t know I had to, but no, I haven’t. I understand the potential side-effects from stopping my medication abruptly. A cold chill goes through me thinking that this is exactly what my patients face, and no wonder they do stop their medications and suffer the consequences. It seems so cruel to me. He asks if I feel better. Well, time is helping heal my emotional wounds that had being inflicted some weeks ago, and I’m pretty sure that would have happened despite the “natural remedies” and acupuncture; but yes, nice man, I am better. Is the “indigestion” better? Am I free of the ‘loose stools’ yet? Yes, nice man, I am free of those things I didn’t even know were problems... Eventually, I’ve spent so much money, I have got so much “better” (judging by what I am telling the nice man), and my self-esteem and normal affect have returned that I just can’t continue this whole thing.

And am I better because of the intricate placebo I have just trialled? Or am I better because I never was ill? I don’t know, but I have at the least realised the effect of faith has on healing. When my patients seek alternative medicine methods, they are usually at their most vulnerable and desperate to be well again. I would be better to see them more frequently, to engage them, to ask (maybe demand?) improvement from them. Maybe if I keep asking them if they are better, maybe if I keep seeing them once or twice a week, maybe if I make them believe the challenge is not just his but his and mine, maybe if I keep asking him to take his medication time and time again, maybe if I pay him personal human to human attention, he will get better. And I think that is the lesson in this for me: that is the kind of practitioner we need to become a bit closer to being, rather than leaving all these tasks to the alternative medicine practitioner, who may or may not also give the best medical advice.

On money and healthcare: Rights & Priorities - Part 3/3

As a doctor you often see people in a very vulnerable state of health walk into your room. Your job is to provide some sort of health care to that person. It is a paid job just like anyone else’s job for which they trained and invested time, effort, and money. Why any of us decided to become doctors and not hairdressers, teachers, politicians, carpenters, etc., is different for everyone and that is not the point. The point is we are workers same as anyone else doing any job. You do the job for a certain amount of hours, you get paid for doing that job, and then the money is yours to do as you wish. That’s the essence of working in a capitalist, democratic country like Australia and the U.S.A. regardless of what your job actually entails, right?

The doctor is a bit like a hairdresser or an accountant or a lawyer or a politician in that he doesn’t physically sell you a product, but rather a service. A patient walks in, you carry out an assessment, work out what he needs, and advice or give that treatment required. Patients don’t leave the room with a new bag filled with products they’ve purchased, but the same thing happens once you leave your hairdresser or accountant – and yet you are aware you need to pay for the service provided to you. And yet you could say that the service provided to you is at least a little more essential than a haircut or advice about things other than your health. One of these things could potentially be the difference between life and death. I have never heard of anyone who risked death by having long or unkempt hair…

So here is the dilemma I wanted to get to: health, or the access to health care is an essential human right; it is a right every human being regardless of who they are or what they possess deserves for the simple act of having being born human. In countries where there is widespread poverty and having no money really means having no money (i.e. none to spare on food or clothing or housing, and not just meaning poor as in having no money for a tv, a car, a haircut, a holiday, or entertainment, etc.), having a right to free access to health care is one of the great achievements of humanity.

So why am I singling out ‘poor’ countries as separate to developed countries like Australia? Because in developed countries like Australia, we believe that if we can’t afford a holiday or a car or costly entertainment that we are poor. And we don’t want to miss out on these things! To a person in a wealthy country like this, we believe that these things are our rights too - and God forbid that we miss out on these things to pay for what we now consider non-essentials, such as our health care. And that is the cause of the dilemma in wealthy countries: we have for the most part changed our priorities as to what is considered essential and non-essential. Yet we all have a sense of what our human rights are. I will tell you that in Australia we see time and time again people who hesitate and complain about having to pay an out-of-pocket fee to have their health tended to, but will without hesitation hand over large amounts of money for haircuts, for manicures, for holidays, for fancy cars, for video games, movies, etc. And yet, only one of these things could potentially be the difference between life and death…

I don’t know what the right answer is. And I don’t know what the best system of health care is. Surely everyone deserves the right to access health care regardless of what they have or who they are or what they do with their lives. Yet, surely, we have also come to some concerning conclusions when tending to our health is considered less of a priority than funding our non-essential commodities. Personally, I have only ever considered the doctor’s role as equivalent to the mechanic’s, to fix the machine so the machine can go where it chooses and do what it chooses. Doing our job doesn’t make us special people, we just do a special task. But it is a job same as being a mechanic is a job - and in this society, a job implies compensation. Doctors eat too and pharmaceutical companies are not charities, so the reality of it is that health care has become a business. It’s not ideal, but it is the reality.

On money and healthcare: Work & Subsidies - Part 2/3

In Australia, up to 80% of general practitioners accept the rebate provided by Medicare as the total cost of their medical consultation service. Essentially that is to say that they provide to Australian citizens with a Medicare card a “free” consultation service with no out-of-pocket cost to the patient (excluding medications sold through a private pharmacist). That’s a great thing for patients! They can’t use the ‘I don’t have enough money to go see a doctor’ excuse too often since most GPs will see them for "free". Of course, the doctor has to get paid, too – because medicine is a job, not a charity – and Medicare will pay him for doing his job. However, remember, how Medicare is a rebate and not meant as full payment of the doctor’s service?...

There is a big group of people in non-government health care systems (e.g. private allied health professionals, private medical specialists, and around 20% of general practice doctors) who don’t accept the Medicare rebate as full payment for the service they provide. Are they the “better” health professionals, worthy of more money than Medicare provides for? Are they greedy ‘fat cats’ like some politicians will call them? No. They are the same as other health care professionals providing similar services. Often they are the same people who will see some patients at a fully-subsidised cost or charge an additional fee on top of the rebate. They’re not bad people; they are just people in paid employment. They’re people working in a private system practising within their legal right to set their own fees for their service, often actually very realistic fees to cover the true costs of doing their job. Unfortunately, because both types of practitioners operate within the same country, the one who charges what he or she has deemed his service is worth is seen as some sort of evil, money-hungry, exploitative person. Conversely, the one who provides “free” (to the patient) services is often considered less than – and this is what most general practitioners in the eyes of the public are seen as.

On money and healthcare: Rights & Systems - Part 1/3

Rights

“Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services”  (Article 25, The Universal Declaration of Human Rights). The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”. Of course, to the majority of the world’s population, complete attainment of our human rights and of health are only ideals and not reality. Nevertheless, they are ideals worthy of our consideration.

Ideals

In an ideal world every time someone fell into an unhealthy situation (physically, mentally, or socially), he should be able to access medical health care, mental health care, or social care and have his “health” restored. He should be able to access these things regardless of the amount of money he has, his sex or age, his political or religious affiliation, his ethnicity or language, his sexual identity or practice, his birthplace or site of residence, his employment status, etc. Basically, his right to health care is universal and his human right. That’s the ideal; reality is very different for a lot of reasons.

Reality

Every country has different health care systems, which impact on the way patients access health care. Some countries will have a health care system that is exclusively government-funded and all you may need to access it is proof of citizenship to that country. Usually that means that there is no cost to the patient for an “encounter” (i.e. every time you access health care) as funds are usually derived from a portion of pooled taxes payed by that country’s citizens. Other countries may have a system where accessing health care requires payment to a private health care facility or a private company that coordinates provision of health care (e.g. supplying and paying for the medical staff’s wages, the medical equipment, the facility fees, etc.). A lot of developed countries, Australia included, operate both of these public and private health systems concurrently where the public system is the default for all citizens unable to afford private health care. The private system exists and thrives because it promises certain perks and advantages like your choice of health care provider, faster access to elective surgery, more ready access to specialist medical reviews and allied health services, and often newer premises, medical equipment, and technologies. And yet other countries have a third system, like a lot in South and Central America, a “worker’s” health care system that provides health care services exclusively to that country’s citizens whose employers pay for access to this service. The worker’s health system is closer (or equivalent) to the private health care system than to the public system. I don’t intend to argue which system is better or which worse or which country does it best, but it’s interesting to consider what’s out there.

Australia

Australia has a dual system of public and private healthcare, the public system funded from federal money and managed (for the most part) at a state level. Medicare can be considered a pool of federal monies reserved for funding certain medical services (including surgical fees and the payment for medical staff), medicines, medical aids, etc. All citizens have access to those Medicare funds provided certain criteria are met, but generally it is a default system for everyone.

An often misunderstood peculiarity of the Australian government’s Medicare system has to do with the way a doctor bills his or her patients. The Australian government decides which medical services are worthy of a Medicare rebate, the amount of money allocated to it, and the conditions under which a service qualifies for a rebate. For example, anybody may approach a general practitioner for medical care and Medicare will provide a certain benefit to the patient to pay for that consultation. The patient may also approach a specialist doctor and pay for the full cost of seeing him in his private clinic; or he may present to his GP first and obtain a written referral to the same specialist and then become eligible for a rebate from Medicare to help pay for his medical specialist appointment. (A patient not wishing to access the private medical system at all for any reason may also be referred to a specialist in one of the state’s hospitals where it is available and obtain medical specialist review free of charge.) Importantly, the Australian government decides which medical services qualify for a Medicare rebate and how much money it allocates to each service – however, how much money Medicare allocates to a service does not always reflect how much money a service actually costs to provide. Medicare in fact operates as a rebate, a subsidy to the total cost of health care, not (at least not always) as the absolute cost to cover the service. Think of it as a discount voucher, not as a voucher for a “free” service.

On telling

I remember as a medical student being told by a psychiatrist who was teaching us about clinical communication skills to always ask yourself “is this for the patient or for me?” A little bit of self-disclosure in clinical scenarios is helpful; it helps establish rapport, trust, and confidence that the person we have entrusted with our psychological care knows exactly what it’s like to be human. That’s the purpose of self-disclosure in medicine, that’s how we can justify telling patients our sins, our glories, and just our everyday occurrences. Besides that, all we are being paid to do is provide a clinical service of diagnosis and treatment. Needless to say, it’s not appropriate to start telling our patients intimate details about our personal lives and thus introduce potentially biasing information that will impact on the patient themselves or their views on us as their clinician or the clinical advise/treatment we provide. But this rule about what we tell and don’t tell got me to thinking to how it applies to life in general, not just as it applies to health professionals.

Two key features of a successful and happy relationship are honesty and trust. You want to be able to trust that your spouse/partner/friend/business associate/etc. is an honest person that does not lie or betray you, right? But at the same time you need to be able to trust that they won’t, otherwise the relationship will be ruined by the constant questioning of their (or your) honesty. Consider, for example, an ideal romantic partnership where the two people involved love and care for each other and have romantic interactions exclusively with each other (including sex, but also other forms of physical or psychological intimacy). That would be a good relationship, right? But what if a similar scenario arose where the two people involved in a romantic partnership love and care for each other and have romantic interactions exclusively with each other BUT the partners were repeatedly asking of the other: “have you slept with anyone else today?”, “have you told any lies to me today?”, “do you love me still today?”, etc. etc. Now, the other partner could repeatedly be honest and say “No”, but isn’t it likely that this good and honest relationship will be destroyed by the lack of trust?

Now consider a scenario where you have the trust but not so much the honesty. You could, for example, have two people who love and care for each other but their romantic interactions are not exclusive to each other. They may every once in a while have sex with other people. They don’t, however, ask of each questions of fidelity, it is only assumed – they assume the other person is honest or sexually monogamous or that they have romantic feelings only for them. You could say that these are either happy human beings or you could say that this is not a good relationship, even if the two parties seem outwardly happy with themselves and each other. You may say that even if everyone it is happy then that happiness is invalid because it is predicated on dishonesty – or better said: lack of honesty.

This ‘happy couple’ to me poses a very interesting human dynamic, because as happy as the members of this couple are and as happy as the whole scenario is, it often fails. And it doesn’t fail because of dishonesty or mistrust. No, it fails, because of misplaced and selfish honesty. Again, let me repeat the scenario. There are two people who love and care for each other and are not unhappy in their relationship, but one (or both) of them engages in an act of intimacy (however you wish to define it) with another person (or persons). They’re not unhappy with each other, their relationship works and is otherwise normal. The relationship can function this way for months, years, decades, or until death parts them. What’s wrong with that? What’s wrong with having a happy life and a happy relationship, right? Well, probably nothing, except that it rarely happens. And I’ll tell you why.

After one of the members of a partnership has committed an indiscretion to whatever gravity, something happens but not to the partner who may be blissfully unaware or to the relationship which still has as much potential as it did before, but something happens to the offending partner. You know what it is? Guilt. Guilt creeps in, escalates by the minute, and this thing we call a conscience tell us that we should tell our partner what we did. It goes over and over in your mind, you convince yourself you are a bad person, you are convinced what you did was wrong, but overwhelming the feeling is guilt. Tony Robbins once said that guilt is really a trigger to correct your behavior, it means you have a standard which you haven’t met and as a result of this failure you feel guilt. That’s the point of it, to correct behavior back to what your standard is.

The truth is most of us do sign up to relationships to be an exclusive intimate partnership between only two people; that’s our standard. That’s what we expect to receive and that is what we expect to give in the partnership. So when we fail, when we don’t reach our own standard, we feel guilty. But what a lot of people do is mistake the trigger to change our behavior for one of simply anxiety or an unpleasant sensation. Therefore instead of thinking that what we need to do is change the behavior, we become convinced all we need to is just to relieve the guilt. So maybe we’ve stopped doing what we once did that caused us to feel guilty initially but we continue to experience the guilt because we can’t forgive ourselves. And we’ll keep feeling guilty until the day we decide to do two things: 1) meet our own standards, and 2) forgive ourselves. The second part is actually a lot more difficult than the first one is, so we often – mistakenly – substitute it. You know what we do when we can’t forgive ourselves? We ask others to forgive us.

When you can’t forgive yourself for cheating in a relationship, even if it was a once-off, we often make the mistake of asking our partners to forgive us. And we ask not because we care about them or because we love them and think they deserve to know the truth. No, I don’t believe that at all (although that is what we tell ourselves and our partner)! We tell of our indiscretions purely as a selfish way to ease our anxiety and guilt. This is what I mean by selfish honesty. There is nothing honorable about wiping your filthy hands on someone else just because you want to have clean hands again. That is selfish, self-indulgent, and spiteful. Don’t get me wrong, though, there are cases when we must confess to our indiscretions, such as, if we have placed another person’s health at risk or there are legal ramifications to our acts, etc. And here is where we need to ask ourselves: “is this for the other person or for me?” What exactly do you expect to gain?

If we tell our stories purely to ease your guilt, then don’t expect a reward for your honesty. I think that is so banal. Yet that is often what a lot of people do, confess their “sins” to their partner, tell them that they are confessing because they didn’t want to lie to them anymore (even though they had caused the other person no harm at all), and then expect to be forgiven because that is exactly what they need to ease their guilt. That is an even greater violation to the relationship. We shouldn’t use our partners to wipe our conscience. If the anxiety of holding a secret is really tearing us apart, if the guilt of what we’ve done is eating us away, there are more responsible ways to deal with it. As I said, what you really need to do is change your behavior. And if you must tell, tell a friend or pastor or psychotherapist, etc. The only reason we should tell our partners - hurt our partners, their self-esteem, their self-worth, their trust, their sense of identity, their faith in you – is to benefit them, not selfishly ease our conscience. And then we must expect not forgiveness but consequence.